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Abstract

Objectives

In China, the rate of downward referral is relatively low, as most people are unwilling
to be referred from hospitals to community health systems (CHSs). The aim of this
study was to explore the effect of doctors' and patients' practices and attitudes
on their willingness for downward referral and the relationship between downward referral
and sociodemographic characteristics.

Methods

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through
random sampling. The questionnaire surveyed their sociodemographic characteristics,
attitudes towards CHSs and hospitals, understanding of downward referral, recognition
of the community first treatment system, and downward referral practices and willingness.
Descriptive statistics, χ
2 test and stepwise logistic regression analysis were employed for statistical analysis.

Results

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although
this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was
influenced by education, understanding of downward referral, and perception of health
resources in hospitals. Patients' willingness was influenced by marital status, economic
factors and recognition of the community first treatment system. Well-educated doctors
who do not consider downward referral would increase their workloads and those with
a more comprehensive understanding of hospitals and downward referral process were
more likely to make a downward referral decision. Single-injury patients fully recognising
the community first treatment system were more willing to accept downward referral.
Patients' willingness was significantly increased if downward referral was cost-saving.
A better medical insurance system was another key factor for patients to accept downward
referral decisions, especially for the floating population.

Conclusions

To increase the rate of downward referral, the Chinese government should optimise
the current referral system and conduct universal publicity for downward referral.
Doctors and patients should promote understandings of downward referral. Hospitals
should realise the necessity of downward referral, effectively reduce workloads and
provide continuing education for doctors. Increasing monetary reimbursement is urgent,
as is improving the medical insurance system.

Background As the age of a population increases, so too does the rate of disability. In addition, disability is likely to be more common in rural compared with urban areas. The present study aimed to examine the influence of rapid population changes in terms of age and rural/urban residence on the prevalence of disability. Methods Data from the 1987 and 2006 China Sampling Surveys on Disability were used to estimate the impacts of rapid ageing and the widening urban-rural gap on the prevalence of disability. Stratum specific rates of disability were estimated by 5-year age-group and type of residence. The decomposition of rates method was used to calculate the rate difference for each stratum between the two surveys. Results The crude disability rate increased from 4.89% in 1987 to 6.39% in 2006, a 1.5% increase over the 19 year period. However, after the compositional effects from the overall rates of changing age-structure in 1987 and 2006 were eliminated by standardization, the disability rate in 1987 was 6.13%, which is higher than that in 2006 (5.91%). While in 1987 the excess due to rural residence compared with urban was 1.5% by 2006, suggesting a widening disparity by type of residence. When rates were decomposed, the bulk of the disability could be attributed to ageing, and very little to rural residence. However, a wider gap in prevalence between rural and urban areas could be observed in some age groups by 2006. Conclusion The increasing number of elderly disabled persons in China and the widening discrepancy of disability prevalence between urban and rural areas may indicate that the most important priorities for disability prevention in China are to reinforce health promotion in older adults and improve health services in rural communities.

Clinical uncertainty is a source of variation in medical decision-making as well as a source of work-related stress. Increasing enrollment in organized health care systems has intensified interest in understanding referral utilization as well as issues such as physician dissatisfaction and burnout. We examined whether primary care physicians' affective reactions to uncertainty and their job characteristics were associated with use of referrals and burnout. Data came from mail surveys of primary care physicians practicing in two large group model health maintenance organizations (HMOs) in the USA. Consistent with past research, we found that younger physicians had higher referral rates than older physicians, and that general internists had higher rates than either family practitioners or pediatricians. Greater stress from uncertainty increased referrals and referrals were negatively correlated with heavier work demands (patient visits per hour). Greater stress from uncertainty, perceived workload (too high) and a sense of loss of control over the practice environment were associated with higher levels of burnout.

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